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Welcome :: Clean Biz
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855-876 CLEAN
                (2532)


* First Name:
* Last Name:
* Street Address:
* City:
* State:
* Zip Code:
* Home Phone:
* Cell Phone:
* E-mail:
How did you hear about us?
 
What kind of cleaning are you inquiring about?
How often do you want service?
On which day(s) would you prefer to receive service?
Monday  Tuesday  Wednesday  Thursday
Friday  Saturday
 
In what type of dwelling do you want service?
How many floors?
How many flights of stairs?
How many bedrooms?
How many bathrooms?
 
What type of kitchen do you have?
 
Please list the types of rooms you have:
Dining Room Living Room Den Parlor Pet Room Office
Play Room Family Room Laundry Room Walk-In Closet
Other rooms not listed:
 
Do you have pets?   Yes No
If Yes, please list:
Are you currently using a cleaning service to mantain your home:
When is the best time to contact you?